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Case of the Week
#156

Clinical
History

A 50-year-old man with a history of heavy
cigar smoking presented with severe inflammation, marked hyperemia and swelling
of the free and attached gingival in the maxillary and mandibular arches. Heavy
plaque accumulation was present around the teeth, and the gingiva bled easily
when touched. Small biopsies were taken.

Clinical image:

Micro images:

Immunostains:

Kappa light chain Lambda
light chain

What is your diagnosis?

Diagnosis:

Plasma cell
gingivitis

Discussion:

Microscopically, there was a dense
infiltration of mature plasma cells beneath the squamous epithelium, separated
by thick collagen bundles. A pronounced lichenoid reaction was seen in the overlying
squamous epithelium. The plasma cells were polyclonal based on cytoplasmic
staining for both kappa and lambda light chains.

The clinical differential diagnosis
includes more serious conditions that affect the gingiva, such as leukemic
infiltrates, multiple myeloma, solitary plasmacytoma (forms a mass, clonal) and
Walden-Strom macroglobulinaemia. Chronic hyperplastic gingivitis usually has
thick collagen fibers and granulation tissue, and lacks an intense plasma cell
infiltrate. Dermatologic diseases that involve the gingiva include discoid
lupus erythematosus, lichen planus and pemphigus.

Treatment includes removal of the
offending substance.

This case was also reviewed by an
oral and maxillofacial pathologist, who noted that for his specialty (certified
by the American Board of Oral and Maxillofacial Pathology), this case
represents non-specific gingival inflammatory hyperplasia, although the
possibility that there could be a drug-related component (phenytoin, Ca-channel
blocker, cyclosporin) would also be a consideration. Clinically, the gingival
tissues would be much more erythematous in plasma cell gingivitis than in the
present case, and the plasma cell infiltrate would be much more diffuse,
essentially mimicking extramedullary plasmacytoma.